Annals of Agricultural and Environmental Medicine 2015, Vol 22, No 2, 385–389 REVIEW ARTICLE www.aaem.pl

Critical Medical Anthropology – a voice for just and equitable healthcare Anna Witeska-Młynarczyk1 1 Institute of Ethnology and Cultural Anthropology, Adam Mickiewicz University, Poznan, Poland Witeska-Młynarczyk A. Critical Medical Anthropology – a voice for just and equitable healthcare. Ann Agric Environ Med. 2015; 22(2): 385–389. doi: 10.5604/12321966.1152099 Abstract The article presents a paradigm current in contemporary medical anthropology – Critical Medical Anthropology (CMA), which merges political-economic approaches with a culturally sensitive analysis of human behaviour grounded in anthropological methods. It is characterized by a strongly applied orientation and a devotion to improving population health and promoting health equity. The beginning of CMA dates back to the 1970s when the interdisciplinary movement called the political economy of health was developed. Today, CMA has grown into one of three major perspectives used in anthropological research devoted to health, illness and wellbeing. The author discusses the origins, key concepts and CMA’s usefulness for social research, and its significance for the design of effective policies in the realm of public health. Examplary interventions and ethnographic researches are introduced and wider usage is advocated of such works and methods by bureaucrats and medical staff for understanding the patients’ behavior, and the influence of social, economic and political factors on the workings of particular health systems. Key words medical anthropology, evidence-based medicine, social justice, cultural diversity

INTRODUCTION Anthropology (CMA) – the paradigm which merges political- economic approaches with culturally sensitive analysis of Medical anthropology advances an interdisciplinary research human behavior grounded in anthropological methods [2]. agenda on contemporary practices related to health, sickness This article presents in a very concise manner the origins and healing, based on ethnographic fieldwork, bringing of CMA, the theoretical and conceptual framework and into focus the social roots of disease and wellbeing. Medical some of the examples of the ethnographic work conducted anthropologists derive inspiration from general social theory, within this paradigm. It can be read as an anthropological as well as, they use inisghts from other sciences such as appendix to the text by Włodzimierz Piątkowski and Michał medicine, psychology, epidemiology or demography. Skrzypek which appeared in an earlier issue of the AAEM, Called a ‘sister discipline’ of sociology, with which it shares titled To tell the truth. A critical trend in medical sociology – major theoretical premises, medical anthropology remains an introduction to the problems [4]. consistent and distinct in its usage of qualitative methodology Works rooted in the CMA perspective constitute a strong with a preference given to long-term participant observation and valuable voice for the humanization of contemporary [1]. However, it is difficult to draw exact disciplinary practices related to health, sickness and the body, which borderlines in current anthropological research focused on the mentioned authors seem to advocate. The critical health, sickeness and healing. anthropologists allow real people to speak extensively about The field of medical anthropology has been developing since the politicalized medical realities of their everyday lives. the 1970s. From its inception, it had an applied orientation These experiences and narratives often remain hidden, i.e. anthropologists were strongly engaged in projects aimed as in the case of the Polish women who use Assisted at improving population health and promoting health equity Reproductive Technology (ART) to become mothers [5]. [2]. Moreover, the emergent approach was characterized by Critical ethnographic insights bring people’s stories to a critical take on biomedical knowledge and practice. By light, in particular the stories of those living at the social biomedicine – also known as scientific medicine or evidence- marigins, and return to them their proper worth. With this, based medicine – anthropologists understand a historically article in turn, I wish to advocate CMA, which is known developed system of knowledge and social practice focused only by narrow circles of professionals. I believe the critical on scientific way of identifying disease and its etiology, as well medical anthropologists can provide unique insights into the as being devoted to the development of a universal system discussion concerned with making medicine more humane. of diagnosing and healing. Medical anthropologists work within a few theoretical orientations. As classified by Ann Critical Medical Anthropology – origins and influences. McElroy and Patricia Townsend [3], these include: ecological The critical perspective fostered by medical anthropologists theories, interpretive theories, political economy or critical shall be considered a part of a larger interdisciplinary theories (i.e. CMA), and political ecological theories. One movement known as the political economy of health. It of the most potent perspectives today is Critical Medical has been diluted within such disciplines as: sociology, geography, public health, epidemiology, economics or Address for correspondence: Anna Witeska-Młynarczyk, Adam Mickiewicz environmental studies. Sal Restivo states that the political University, Institute of Ethnology and Cultural Anthropology, ul. Św. Marcin 78, 61-809 Poznań, Poland, http://etnologia.amu.edu.pl economy of health E-mail: [email protected] is a theoretical framework used to study health inequalities. Received: 06 November 2013; accepted: 28 March 2014 It proposes that health disparities are determined by 386 Annals of Agricultural and Environmental Medicine 2015, Vol 22, No 2 Anna Witeska-Młynarczyk. Critical Medical Anthropology – a voice for just and equitable healthcare

social structure and institutions that create, enforce, and wellbeing are recognized by engaged anthropologists as the perpetuate poverty and privilege. […] [Political economists most serious contemporary global challenge. of health – AWM] analyze the relationships between health In the 1980s, with the advancements in poststructuralist status and political-economic institutions throughout the thought, the concept of biopower authored by Michel Foucault world, with particular emphasis on the detrimental health [12] became popular among social scientists. Biopower refers effects created by capitalist relations of production and to a new form of social control which emerged within the sustained by specific political-economic arrangements [6]. context of a modern nation-state. This kind of control based on specific modern regimes of knowledge and practice – The critical approach to health and illness is rooted in the e.g. hospital, public health or population measurement Marxist tradition. Friedrich Engels’ book The Condition of techniques – is not achieved through coercion but through the Working Class in England [7] constitutes the classic of dissemination of knowledge in an institutionalized form, for critical analysis of disease understood as socially conditioned example, in schools. Such knowledge appears natural and and dependent on power and class relations. Another normal to people and becomes the basis for their behaviours, early intellectual influence was the German pathologist- choice-making and self-perceptions. With reference to the anthropologist Rudolf Virchow (1821–1902), who gained human body and health, it implies internalizing various fame with his socially-sensitive study of a typhus epidemic body techniques (such as diet, sexual behaviour or drug that broke out in Upper Silesia in 1848. intake) and cognitive schemata (such as the tendency to make The beginning of critical perspective in medical oneself responsible for ill health as opposed to, for example, anthropology dates back to 1973 and the symposium Topias recognizing the social determinants of illness). and Utopias in Health organized for the Ninth International More recently, CMA has also been increasingly sensitive Congress for Anthropological and Ethnological Sciences. to phenomenological thought moving away from the pure Important later developments were: Soheir Morsy’s ‘The Foucauldian mode of presenting patients as docile bodies, Missing Link in Medical Anthropology: the Political and penetrating the subjective dimension of health and Economy of Health’ [8], published in Reviews in Anthropology, sickness, treating patients as furnished with agency [13]. and Hans Baer’s essay ‘On the Political Economy of Health’ These developments coincide with the growing interest of the published in the Medical Anthropology Newsletter [9]. These social sciences in the body as a significant component of the essays constituted an overview of the field of the political contemporary culture and mode of self-construction [14]. economy of health and aimed for the inclusion of its program Eventually, contemporary critical thought tries to merge into the anthropological agenda [10]. Anthropologists’ both structural and individual levels of analysis. It focuses warming up with the political economy of health shall be on the interaction between individual agency and social understood as a part of a larger process. The 1970s in the processes of which institutional and discursive power is a United States were marked by a general growth of interest part [15]. It uses the critical theoretical framework to unmask in the political economy of health caused by revitalization of hidden sources of social inequality and ill health, both in the Marxist scholarship and the world system theory, as well as global and local dimensions. the voicing of such social movements as feminism, civil rights and the anti-war movement [6]. Nowadays, critical medical Critical Medical Anthropology – classical key concepts. anthropologists enter into their studies beyond class and look Merrill Singer, a critical medical anthropologist, distinguishes into stratification due to race, gender, ethnicity, religion or seven key concepts in CMA: health, disease, syndemics, sexual orientation as determinants of ill health. sufferer experience, medicalization, medical hegemony Deriving from Immanuel Wallerstein’s World System and medical pluralism [2]. Health in CMA is defined as: Theory [11] developed in the 1970s, critical medical ‘access to and control over basic material and non-material anthropologists look at their subject from a larger perspective resources that sustain and promote life at a high level of and recognize that ‘disease and its treatment occur within satisfaction’ [2]. Disease in this approach is seen as both the context of the capitalist world system’ [10] which has biological and social, and the critical analysis is meant to produced new global and local configurations of class discover the relationship between the biological and social relations and structural inequalities. The World System roots of the disease. Social epidemiology linked to CMA Theory developed by I. Wallerstein is a socio-historical kind of preoccupies itself with identifying social determinants of analysis explaining the modernization process from a global population distribution of health and disease asking: ‘Who perspective, with emphasis being placed on the changing and what is responsible for population patterns of health, nature of capitalism and related to it the supremacy of the disease, and wellbeing, as manifested in present, past, and Western world. Wallerstein developed a ‘core-periphery’ changing social inequalities of health?’ [16]. CMA studies, model arguing that the development of world capitalism very much aware of social inequalities, look at ‘biological produces the wealthy metropolitan core which extracts goods expressions of social inequalities’, i.e. ways in which people and services from the poor peripheries [11]. From this point of biologically live through economic and social inequalities, view, underdevelopment of the Third World is understood as a and how such inequalities are being transcribed into the body consequence of the expansion of world capitalism, as opposed – a phenomenon called by Margaret Lock and Vinh-Kim to late modernization or backwardness [6]. Critical medical Nguyen local biologies [17]. One example of a recent work on anthropologists are particularly interested in such issues local biologies is Clara Han’s Life in Debt, which describes the as the advancements of biomedicine into this unprivileged reality of poor people living in the neighborhood of Santiago area of the world, and the consequences of these processes in Chile. She studied an impoverished group of people once on the wellbeing of the local populations, or exploitation of marked by political violence and interpreted the mental indigenous knowledge and practices by the pharmaceutical health disorders present in their lives in relation to neo-liberal industry. Poverty and inequalities in access to health and Chilean policies and rhetoric of reconciliation of the 1990s Annals of Agricultural and Environmental Medicine 2015, Vol 22, No 2 387 Anna Witeska-Młynarczyk. Critical Medical Anthropology – a voice for just and equitable healthcare

[18]. Paul Farmer’s body of work on AIDS is an important that the phenomenon of medicalization is coupled with the example of engaged critical work which reveals that poverty processes of demedicalization, i.e. social behaviours set in plays a key role in the contemporary spread of pandemics in opposition to medicalization. CMA built upon the concept of various localities such as Haiti, USA or India [19]. medicalization by relating it to the global capitalist economy Another key concept – syndemics, was introduced by and added a new phrase to the socio-medical dictionary i.e. CMA in the mid-1990s [20]. It can be read as a critique medical hegemony. By medical hegemony CMA understands of the practice of treating disease as isolated and distinct the global expansion of biomedicine as knowledge and practice entities, independent of social contexts. It refers to two along with ‘the process by which capitalist assumptions, or more epidemics and how they interact synergistically concepts, and values come to permeate medical diagnosis inside human bodies, contributing to an excessive burden of and treatment’ [2]. The hegemony of biomedicine, according disease in a given group of people [2]. For example, the non- to CMA, should not be understood as a consequence of its governmental organization Partners in Health (PIH) argues curative efficacy but as a result of expansion of global market that most of the global vertical health programmes aiming at economy [10]: combating HIV/AIDS in rural areas of Africa or in Haiti were Hegemony refers to the process by which one class exerts ineffective because they did not recognize that most of the control of the cognitive and intellectual life of society by patients came to see a doctor because of other ailments (most structural means as opposed to coercive ones. Hegemony is notably, people diagnosed with HIV/AIDS suffered from achieved through the diffusion and constant reinforcement tuberculosis). PIH therefore suggested linking programmes through the key institutions of society of certain values, combating HIV/AIDS with those addressing tuberculosis. attitudes, beliefs, social norms, and legal percepts [2]. These suggestions were based on well-grounded research conducted, among others, by critical medical anthropologists Research based on CMA may, for example, look into (see: http://www.partnersinhealth.com). programmes promoting health as a form of pedagogy which When CMA focuses on the individual sufferer’s experience legitimizes ideologies and practices shaping individual daily it never looses sight of macrosocial processes. The assumption lives in terms of food intake, physical activities, sexual is that the way people live through sickness depends on socially behaviour, reaction to distress and suchlike [21]. constructed meanings and the political and economic forces CMA’s interests in biomedicine can be expressed in the that shape daily life. Research programmes conducted in the question of who controls it and what are the implications CMA paradigm are meant to help improve people’s health of such control. More specifically: Who has power over the and wellbeing, hence its interest in poverty, deprivation, agencies of biomedicine? How and in what form is this power social exclusion, and inequalities. Recent theoretical focus on delegated? How is this power expressed in the social relations the human body observable in anthropology has influenced of various groups and actors that comprise the health care the way CMA approaches the individual experience of system? [10]. wellbeing and illness. In CMA, the body is analyzed not In the CMA approach, studying health practices around only as embodying social and economic inequalities, but also the contemporary world entails a critical reflection on the in the context of contemporary commodity culture. Today, Western domination in the field of health maintenance and people express and define themselves through commodities healing. For example, medical anthropologists preoccupied and appearance which reflect their concepts of self and the with the concept of Global Mental Health (GMH, i.e. an world. Attention to body maintenance implies interest in good emerging form of knowledge and practice focused on global health, sexual attractiveness, and a desirable external look. An dimension of mental health exercised, among others, by immense demand on industry devoted to bodily maintenance World Health Organization (WHO) through the Mental means further expansion of biomedicine into new fields – Health Gap Action Programme (MHGAP), which is for example, that of the human appearance [21]. In this way meant to fight inequalities in access to mental health care pharmaceuticals have become central for the contemporary in poor countries, point out that GMH programmes are sense of self and the way people represent themselves vis- dominated by western modes of diagnosis and treatment of à-vis others and relate to their social environment. Emily mental illness, among others, according to the interests of Martin called this phenomenon the ‘pharmaceutical self’. In pharmaceutical companies and the establishment of standard her public lecture at the British Museum she described, for northwestern psychiatry. They argue that, inter alia, due to example, how psychotropic drugs are imagined by Americans cultural differences, western diagnostic manuals for mental as means for improving oneself [22]. João Biehl develops this illness should not be treated as universally applicable [26]. argument in his discussion of the complexity of becoming An aggressive process of introducing mental health care in a ‘pharmaceutical self’ by presenting the ethnographic case the Third World modeled after Western medical systems is of a Brazilian woman diagnosed with mental disorders who driven by specific economic interests and proves that various was deprived of social networks support, and for whom medical traditions are differently valued by international pharmaceuticalization meant development of dependency agencies. This process, in turn, reveals asymmetries in on medical and social institutions which led to further social power relations between the South and the West. In fact, alienation [23]. anthropologists observe some resistance to biomedical One of the most important terms in medical anthropology hegemony which is often understood by local populations is that of medicalization. The notion was popularized by as a form of colonization. Such resistance may be expressed the sociologists Ivan Illich [24] and Irving Zola [25] in through support given either by the State administration the 1970s, and describes the process of rapid expansion or by lay people to local medical traditions, as opposed to of scientific medicine into various walks of human life biomedical practice, as it is in Indonesia, for example [27]. (e.g. medicalization of old age). It is important to note that Yet, as illustrated by Guillaume Lachenal for the Democratic recently, sociologists and anthropologists have observed Republic of Congo, biopolitics in a form of bureaucratic 388 Annals of Agricultural and Environmental Medicine 2015, Vol 22, No 2 Anna Witeska-Młynarczyk. Critical Medical Anthropology – a voice for just and equitable healthcare reinforcement of modernizing health reforms based on physicians [10, 33], which is linked with the fact that western the western model may be also thought of by people with health care institutions start to operate on such market- nostalgia and desire, as opposed to threat or repugnance [28]. driven assumptions as profit-making entities under the guise Anthropologists are well-trained to show such culturally- of ‘managed care’, which is increasingly bureaucratized and conditioned differences, also those differences which surface where the physician looses much of his/her autonomy. among Western societies. Eventually, the key concept in medical anthropology, as CMA is critical because it preoccupies itself with unmasking such, is that of medical pluralism. The term implies that in the profit-making orientation of biomedicine heavily reliant contemporary societies a number of healing traditions are on high technology, massive use of drugs, and concentration present. Singer suggests that in most cases national medical of medical services in medical complexes [10]. National systems are ‘dominative’, i.e. one medical system (most often bureaucracies are seen as entities which give legitimacy and biomedicine) enjoys dominant status over other practices help maintain the corporate dominance in health arena, (e.g. ethnomedical practices) [34]. It may work towards among others, through the shaping of medical training or subordinating other medical traditions operating within a national health programmes. The same applies to international given society. Such a status is possible thanks to the support actors like the World Bank or IMF which influence the of the elites of society and legal solutions giving biomedicine health policies of the countries receiving financial assistance, monopoly over certain medical practices. Anthropologists demanding health care reforms developed in accordance with mention also examples of heterodox medical systems (also the rules of market-driven economies [10]. known as medical hybridization), like Ayurveda and Unani The critical character of CMA can be traced in its in India, natural medicine in Germany, or two medicines preoccupation with the functioning of the pharmaceutical in China [27]. Danuta Penkala-Gawęcka distinguishes also companies [29], which, today, – as pointed out by Kalman microsocial perspective on medical pluralism, i.e. individual Applbaum – increasingly resemble fast-moving consumer patients’ decisions to use services stemming from different goods companies selling detergents, beverages or hair sprays. traditions concurrently or interchangeably, as well as a This author argues that marketing became the driving force reliance on various health ideologies when living through in the drug industry leading to such developments as: one’s illness [35]. Many social scientists notice that the 1) seeking to lower costs through foreign sourcing of raw western biomedical model undergoes a crisis and that there materials – in this case clinical trial subjects; is a move towards demedicalization [36, 37, 38, 39]. Critical 2) seeking to expand the market for one’s products by medical anthropologists see in this a proof of agency and a exporting to new markets and by deepening consumption potential of individual choice-making for bringing in a social in existing ones; change. The term medical pluralism has undergone some 3) muscling into local healthcare policy and administration criticism. More recently, terms like multiple medical realities to guarantee country environments healthy for phrama [40] or medicoscapes [41] have become more popular. They growth. help grasp the transnational aspects of medicalized social life and research the heterogeneity of the actors involved in Applbaum argues that citizens in western countries have the production of the individual sense of health and illness. become over-medicated and, as such, are less useful for medical trials; the search now is for ‘naïve’ populations, i.e. A vision of social justice and political economy of health. those living in poor countries. This tendency is problematic, The CMA approach to health and illness seems particularly both ethically (new drugs are unaffordable for the tested potent for analyzing national contexts of countries undergoing populations) and from the medical point of view (drug political and social transition, for example, Poland. Recent efficacy may vary cross-culturally) [29,30]. An approach reforms of health care meant transformation from the tracing the social life of pharmaceuticals constitutes a crucial socialist model based on the assumption of equity, yet, lacking field for contemporary critical research [31]. It deepens in resources, to the commercialization of health care, which knowledge concerning the local conditions of production implies differentiation in access to health care, a growing and consumption and the functioning of the pharmaceutical gap between rich and poor in the quality of received care, industry. Using a ‘biography’ metaphor, anthropologists and an expansion of medical technology. Anthropological deconstruct various stages of pharmaceutics’ life, such as cross-cultural studies may help contextualize and compare the production, introduction to the market, distribution, the Polish medical system and the relationship between prescription, sales and usage [32]. the historically changing political regime and provision of On a mezzo-level of analysis, doctor-patient interactions health to that of other countries. Restivo warns that ‘Health are approached in CMA as an example of hegemonic practice is increasingly constructed as a pathway to economic growth reinforcing the non-egalitarian structures of society. On and development, as well as an untapped source of revenue the one hand, it is about placing the patient in a position for the private sector’ [6]. Addressing inequalities in global of subordination to a medical expert, on the other, about health and recognizing its local consequences requires directing the patient’s ‘attention to the immediate causes decisive steps taken by the governments to protect their of illness, such as pathogens or bad habits, and away from citizens and physical environments. The vision of social structural factors of which doctors feel they have little justice implies that the interests of corporate agencies and control’, e.g. working conditions or material deprivation. capitalist logic are set aside and a priority is given to a joint The doctor in the patient/doctor relationship plays a two-fold action of building a just and equitable health care which social role: he/she controls access to the sick role and he/she works towards combating human poverty [42]. As Nancy medicalizes social distress [10]. Another problem posed by Krieger put it: ‘If you have a social justice perspective on critical thinkers on the intermediate level of analysis is the public health, it means that you have to seriously engage with process of deprofessionalization or proletarianization of the political economy of health’ [43]. Annals of Agricultural and Environmental Medicine 2015, Vol 22, No 2 389 Anna Witeska-Młynarczyk. Critical Medical Anthropology – a voice for just and equitable healthcare

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